The objective of this study was to
understand the coping mechanisms of men living with HIV/AIDS in terms of their
work environment. A qualitative study was carried out at a specialized
outpatient clinic in Fortaleza-Ceará between March and June 2010, involving
eleven men infected with the virus. Semi-structured and audio-recorded
interviews were used. The statements were categorized through content analysis
into the following categories: absence from work due to the infection;
subterfuges used to hide the disease; disrespect for confidentiality in the
work environment; suffering associated with the fear of rejection and
prejudice; ways of coping after diagnosis of the disease; and the importance of
work for personal accomplishment. In conclusion, men infected with HIV face
counterproductive situations in the work environment, mainly evidenced by fear
of discovery of the infection and prejudice. Associated with coping, absences
for health monitoring purposes interfered with performance at work and
increased the risk of losing their job.

When a
person discovers that she/he is infected with HIV, it marks the course of their
and their family's lives because of the acceptance, adaptation and
incorporation of new behaviors to keep healthy and, thus, prolong life to the
longest.

In view of the increased life
expectancy of infected individuals, AIDS is now referred to as a chronic
disease, which implies new challenges to patients and healthcare professionals,
which include: the social reinsertion in the labor market and in school, the
promotion of healthy habits, including eating with quality and exercising, as
well as maintaining sexuality, with the right to motherhood and fatherhood(1).

The social inclusion of
HIV-positive individuals in the workplace is considered positive for their
quality of life. However, the reality that is observed is one of discrimination
by employers as well as co-workers. This fact culminated in the exclusion of
the most elementary citizenship rights, with includes work(2).

In addition to this problem,
workers suffer several forms of discrimination, which are evidenced by: the
obligation to take anti-HIV tests during recruitment and, consequently, not
being hired in the case of a positive test result; dismissal because of a
positive HIV-test result; being excluded from the training program and from
promotion opportunities; ostracism by co-workers; exclusion from the company's
health plan, among other forms of prejudice(3).

In order to focus on the coping
experiences of men with HIV in the labor market there is a need for a renewed
view, which, in turn, requires a scientific and intellectual attitude that
integrates social inclusion and its relationships with the working world(2).

Workers
have to foster the pathways to live in a structure and assign new meanings to
life values and healthcare. Here, one's perception of the contradictions
regarding their body emerges as a fully concrete fact. They gain a
destructuring outline that is far from being organized or controlled, being
fascinating and frightening at the same time. The body, initially criticized as
a source of pleasure purged by the infection, is now seen as a working tool,
which generates a duality between the anxiety towards the disease and the
production regulation that apparently has no direct relationship with the
training and qualification for the job, gender, age, competence and abilities,
time and movement, rational and logical investments of the act of working,
technology, workers' rights, and others.

Reflecting about these aspects,
it is worth illustrating that the AIDS epidemics accounted for the death of 28
million workers worldwide until 2005. The problem and its solution still
require further explorations and the discovery of meanings that would minimize
the restlessness before the social neglect that still persists in society. We
live a tendency without setbacks or hesitations. By 2015, the toll of the
disease will have been 74 million lives. This situation places AIDS as a
significant cause of death in the working world, definitely affecting the
social, economic and cultural structure of countries, and, thus, consisting of
a serious threat to the working world(4).

The
challenge for creating devices to support initiatives to cope with the disease,
assumed by government leaders and institutions such as the World Health
Organization (WHO) and International Labour Organization (ILO) originated the
Consensus Statement on AIDS and the Workplace. As stated, work does not promote
any risk of the virus being acquired or transmitted from one worker to another,
or from a worker to a client, or from a client to a worker. It is also
reinforced that HIV infection is no reason to end the work relationship(5).

In
Brazil, since the early 1990's, it has been legally prohibited, in the federal
public service, to demand HIV tests in pre-employment and periodical health
examinations; it is stated that being HIV-positive does not harm the
individual's working capacity, and maintaining a social and professional
contact with HIV-positive individuals does not configure a risk of becoming
infected(6).

The
highlight on establishing risk-free relationships in the workplace encompassed
new elements of the working condition; however, the everyday existence of this
relationship does not set limits to sharing cultural values and ideas that
permeate the whole process of being inserted in the working world, and, for
this reason, the referred consensus statement does not address the thought that
the worker is exposed to other life fragments that limit their interactions
within the workplace.

From
the perspective of labor relationships/employment, AIDS brings the following
issues into discussion: the management of the working processes, the
fundamental rights of the worker and changes in the working world that involve
a network of complex relationships mechanisms and activities of HIV-positive
workers. It is important to outline that many workers express wishes different
from that of the other workers, which directly refer to clear acknowledgement
that work is a factor that links health and disease. Factors such as
unemployment, informal employment, and, most of all, being excluded from the
labor market become associated and lead the individual towards a worsened
health condition(7). On one side, there is a contradiction that
defends the individual's right, as a citizen, to work, not being discriminated,
and the confidentiality of their health condition, while on the other side,
there is the community's right to health(8) and also the authority
and power of the organization, which is prepared to generate profits and defend
the economical interests.

In
the workplace, AIDS is not understood as a disease similar to others to which
the company and institutions owe certain responsibilities, as segments of civil
society. Contrarily, the disease causes problems in the workplace, as the
companies are incapable of managing the situation(9).

There is evidence of the need
for companies to disseminate the recommendations reported by public
organization such as the ILO so that the rights of HIV-positive individuals are
respected, which include: not performing an anti-HIV test in the pre-employment
examination; maintaining workplace confidentiality of any information regarding
the disease as well as avoiding any situation that could cause constraint or prejudice
towards the worker and strict rules regarding the confidentiality when
accessing the personal data about a worker's HIV.

Within this context,
recognizing the contradiction of the working world and the ways of coping used
by the HIV-positive men in their everyday practice in view of the scarcity of
studies on this issue, justify developing the present study.

OBJECTIVE

To
understand the coping situations that HIV-positive men experience in the
workplace.

METHOD

This is
an exploratory, descriptive, qualitative study. Literature states that the
qualitative approach permits to elaborate answers to intricate and particular
questions, because it works with the universe of meanings, values, beliefs,
motives, aspirations and attitudes. Thus, its focus transcends the mere
operationalization of variables, and encompasses a deeper area of
relationships, processes and phenomena(10).

This study was developed during
the months of March and June of 2010, at the HIV specialist ambulatory service,
at Hospital São José de Doenças Infecciosas (São José Infectious Disease
Hospital) in Fortaleza-Ceará. The participants were eleven HIV-positive
men. The selection criteria were: 18 years of age or older; male; refer being
employed or having been employed some time after becoming aware about their
being positive for HIV. The number of subjects was not determined based on a
numerical representation criterion, but on the representation regarding the
sharing of experiences considered fundamental for the investigated issue. The sample
size was not determined, but the group of participants was considered
appropriate to portray, by means of interviews, the experiences, meanings,
values and behaviors associated to coping with various situations in the
workplace in view of the HIV infection.

Data collection was performed
using a semi-structured form aimed at gathering information regarding the
participants' identification and the situations they have experienced in the
workplace that are associated to their being HIV-positive. With the purpose to
unveil the study objective, the following guiding question was used: Could you
tell me if you have ever experienced any situation of constraint or happiness
at the workplace related to your positive diagnosis for HIV?

With a view to guarantee the
quality and trustworthiness of the data, the interviews, which lasted
forty-five minutes, were audio-recorded upon the participants' consent and were
performed in a private room.

As recommended, the interview
contents were fully transcribed and subjected to content analysis. Literature
defines this method as a group of communication analysis techniques that aims
to achieve, by means of systematic and objective description procedures of the
message contents, indicators that would allow for inferring knowledge related
to the conditions in which these messages were produced and received.
Therefore, it permits to analyze the participants' opinion, in between the
lines, i.e., not being exclusively restricted to words that are stated
directly, but also those that are implied in the discourse(11).

The analysis originated the
following categories: absence from work due to the infection; subterfuges used
to hide the disease; disrespect for confidentiality in the workplace; suffering
associated with the fear of rejection and prejudice; ways of coping after
diagnosis of the disease; and the importance of work for personal
accomplishment.

As
required, the study complied with the recommendations of resolution 196/96
regarding studies involving human beings and was approved by the Research
Ethics Committee at Hospital São José de Doenças Infecciosas, under
protocol number 60/2009. All the participants provided written consent. Aiming
at preserving the subjects' identity, they were referred to by using the letter
"I" (interviewee) follower by numerals according to the order in which the
interviews were performed.

RESULTS

As
mentioned above, the participants were eleven HIV-positive men, of age between
25 and 50 years. The mean education time of the participants was 8.7 years,
while the interval time since they became aware about the infection was from
one to nine years. In terms of their employment situation, four men were unemployed,
three had a formal job, three had informal jobs, and one was retired due to the
serious effects of the disease. The income of most participants was between one
and two minimum salaries (at the time the minimum salary was R$ 465.00, or US$
233.00).

The participants' statements or
discourses are presented in Chart 1. This chart shows the categories and main
excerpts related to the participants' experiences and their ways of coping with
situations at the workplace associated with being HIV-positive.

DISCUSSION

The
analysis of the data in the category Absence from work due to the infection revealed that men stated that in order to look after their health, it was
required continuous and periodical medical follow up. These conditions are
inherent to the HIV treatment, which require monthly or periodical appointments
at the health service, causing work absences or delays because the health
service is open only during business hours. Therefore, the workers' constant
presentation of medical notes, despite not including any information stating HIV/AIDS,
marks the beginning of a process of visibility of their condition and their
stigmatization.

It was observed that the
individual's health status affected their decision about staying or not in the
job. In order to avoid embarrassing situations, in addition to choosing to
remain silent, the patient quits the job if any collateral effects of the
antiretroviral medication or symptoms that indicate an advanced disease status
emerge.

Within this context, it was
evidenced that companies have weaknesses in terms of dealing with issues
specific to the disease, such as the workers' having to leave work because of
medical appointments and the fear of transmission within the workplace. In
fact, the logic of the capitalism at the national level contributes with this
deficit, most of all because of the legal determination regarding the
responsibility that companies and institutions have towards their employees
with HIV. This issue is present in between the lines of the recorded statements(9).

As indicated in the category Subterfuges
to hide the disease, studies show these situations when they reveal
that HIV-positive workers are often dismissed, or not hired, because, in order
to follow their health condition with medical care, the employee has to be away
quite often, due to appointments, examinations, or, yet, to obtain medications
(12).

Also
regarding the statements of this category, as can be seen, workers with
HIV/AIDS choose not to reveal their diagnosis, fearing embarrassment and losses
at work, besides likely being dismissed.

In
general, the coping phenomena understood through the subjects' statements
reveal a diversity of anguishing feelings, such as fear, shame, stigma, and the
social isolation in view of their discovering the diagnosis, issues mentioned
in the category and found in literature(13).

Regarding
the category Disrespect for confidentiality in the workplace,
confidentiality regarding the disease is justified by the subjects as a form of
protecting themselves from prejudice, discrimination and shame, set by the
social representations of HIV/AIDS.

After
becoming aware about the diagnosis of the disease, the HIV-positive patient
faces, within their environment of social interaction, the experience of being
exposed, discriminated against and isolated. Therefore, the individuals are
required to learn how to cope with the situation, which requires obtaining
social and personal resources. In view of this situation, these patients prefer
not to comment about their health condition with others, and, therefore, try to
hide any information that would disclose their condition, by establishing
certain criteria to avoid any socialization(14).

In an
attempt to hide the disease, many patients omit their true health conditions when
asked about the treatment that force them to attend the health service so
frequently. However, according to the statements of the present study subjects,
not always is it possible to maintain confidentiality, and, when their health
condition regarding HIV is disclosed, employers and co-workers demonstrate
prejudice, exposing the patient to a situation of constraint or even their
voluntary or arbitrary dismissal(14).

The
infection by HIV does not justify dismissing the individual from work. People
with HIV and any associated disease are capable of working in a location
considered appropriate and clinically adequate for performing the professional
activities.

What
has been defended for long is guaranteeing the job of individuals with HIV:
their job contract cannot be terminated by theme simple fact that they carry
the virus in their body. Thus, the guarantee of employment would be the
workers' right to remain in their job, protected under the Constitution of 1988(15).

In the category Suffering
associated with the fear of rejection and prejudice, the individuals with
HIV feared that if their co-workers found out about their health condition,
there would be prejudice. In some cases, the fear of transmission also
generates a certain discomfort at work, while in others, discrimination becomes
a strong factor for their not returning to work(16).

When referring to AIDS, fear
was often emphasized and the existence of the disease appears as a threat. The
possibility of being infected raises concern, because AIDS is represented with
great dread. Furthermore, the fact that there is no cure for the disease and
the risk of infection suggest a catastrophe that, often, should not even be
mentioned (17).

When diagnosed, AIDS overwhelms
the patient with doubts and uncertainties; such as whether the disease will
develop or not and how painful and inevitable its progress will be, forcing the
patient to live permanently with the certainty of an early death(18).
In addition, the patients' concern about their infection being revealed is
often self-imposed by the fear of being subjected to prejudice and
stigmatization(12).

As
observed, some patients who were employed, quit their jobs because of the fear
of being known to have HIV; others were fired because of prejudice; and others
gave up on looking for a job due to their fear of pre-employment examinations.

However,
it is illegal to force candidates to taking an anti-HIV test, in addition to
being highly discriminatory, as determined in several legal ordinances, such as
Law number 9029/95. Similarly, the ministerial decree 869,
of 11 August 1992 prohibits: in the federal public service,
to demand a test to detect the human immunodefi-ciency virus in either pre-employment or periodical health
examinations(6).

According
to the statements, today, many of the subjects are either unemployed or keep an
informal job. They fight to get their retirement or right to sickness allowance
to minimize their financial burdens. Jobless, they become anxious and
depressed. They were once contributors and now they see themselves as a burden
to society.

In the
study, some reports referred to episodes of discrimination at the workplace due
to the lack of confidentiality by others who became aware of the worker's HIV
infection.

Hence,
it is understood that the issue regarding the disclosure, at the workplace, of
the worker's condition of being HIV-positive is complex and represents a threat
to their continuing in the job. When their HIV-positive status is
revealed to their superiors or co-workers, they face difficult situations at
the workplace. It is, therefore, necessary to deal with the prejudice of
withdraw from peers. Within this context, the results confirm that their
silence represents a search for self-protection and a way of coping with HIV/AIDS.

Thus,
one of the problems revealed in the workplace is the fear of their co-workers
finding out about their infection, and the resulting prejudice. In some cases,
the fear of transmission also causes a certain discomfort at work(16).

Many of the perverse
consequences of the stigmatization of people and/or specific groups involve
discrimination in public spaces and private institutions, which generate
hostility, segregation, exclusion and/or self-exclusion of individuals whose
HIV-positive status is revealed. The AIDS stigma overlaps the
preexisting stigma associated with different social groups, such as
homosexuals, sex workers and drug users, thus evoking multiple meanings. These
pre-conceived concepts and images are part of a cultural and social matrix that
establishes differences, creates hierarchies, and sanctions structures of
social
inequalities(19).

The few subjects that revealed
their HIV-positive condition to some people reported experiencing prejudice
from their friends or at the workplace.

By observing the statements in
the category Ways of coping after diagnosis of the disease, it is
evidenced that the subjects seek different forms of minimizing the suffering in
face of their unemployment.

Facing or coping with these
situations triggers deep stress in these individuals. According to literature,
this type of coping has been defined as the cognitive and behavioral efforts
towards managing the intrinsic and extrinsic demands of the individuals, which
are evaluated as an overburden to their personal resources (20).

Therefore, living with a
disease that implies discrimination, such as AIDS, requires the individuals to
deal with different situations. In this setting, the search for religious
support has been one way of achieving adaptive results in the process of coping
with AIDS.

In
the present study, taking initiative and having the courage to face the disease
start with believing in a God; next, the patient's decision to seek
alternative therapies is used as an attempt to dodge the different coping
situations.

As observed in the category The
importance of work for personal accomplishment, having a job surpasses the
individuals' economical needs, it is, most of all, a source of well-being,
self-respect, dignity, self-esteem, and citizenship. These feelings can improve
their quality of life, and promote social reinsertion, considering that
working means they are contributing with the society, hence they feel useful(21).
This is further evidence when gender issues are considered, because for men
work is a source of social identity(16).

The process of disseminating
the news about the HIV infection proliferates an epidemics of meaning,
implying that the individual must constantly cope, either in silence or
explicitly, with stigma and discrimination(16). To men, living
intensively and with quality of life requires relating with the world, and,
most of all, counting on the support from family, friends and from those from
the workplace(22).

CONCLUSION

In
general, it appears that living with HIV in the work environment is not a
harmonious situation. The diagnosis of the disease triggered a series of
experiences with different effects on the HIV-positive individual, most of
which are counterproductive. Furthermore, the need to feel useful and
productive contrasts with the obligation of being absent from work due to the
manifestations of the disease and attending clinical follow up.

In
view of the fear of having their diagnosis revealed and, thus, produce feelings
of prejudices and rejection from employers and co-workers, the HIV-positive men
choose to be silent about their disease and consciously decide to quit their
jobs as a coping strategy. There were also reports of the embodiment of
prejudice, evidenced by the disrespect of the confidentiality, dismissal after
knowing about their diagnosis and several other situations that caused
constraint at the workplace.

This study reinforces the
thesis that understanding the issues related to HIV infection among productive
men is a complex task, as they carry the stereotype of a disease associated
with connotations of devaluation, which have an impacting effect on their right
to work. From this perspective, the present study findings may help companies
and employers reflect about how to support and include HIV-positive workers in
the work environment. On the other hand, workers should also seek asserting
their legal rights, through and active by notifying situations involving
prejudice and exclusion at the workplace.

This study does not aim to
exhaust the investigation about experiences and the ways that HIV-positive men
cope with the disease in the labor market. Rather, the purpose is to raise
awareness about the theme, as a first step to implement specific methodological
approaches, as well as the utilization of a larger study sample. Further
studies should investigate the social representations of employers towards HIV.
Moreover, interventional studies should be performed, in addition to
investigations of public policy studies that encourage including HIV-positive
individuals in the context of labor should be prioritized.

In
view of this reality, it is highlighted that nurses, particularly those who
specialize in occupational nursing, are promoters of the support and inclusion
of HIV-positive individuals in the workplace. Therefore, we hope to encourage
equal and humanized treatment, free from prejudice, that would promote, above
all, the quality of life of this clientele in terms of work, which is
considered one of the main forms of affirmation of men.

Acknowledgements

The authors thank FUNCAP - Fundação Cearense de Apoio ao Desenvolvimento Científico e
Tecnológico, CNPq  National Council for Scientific and Technological Development and CAPES -
Coordenação de Aperfeiçoamento de Pessoal de Nível Superior for the fellowships granted to
the students during their Master studies.